Judicial decisions

A non-exhaustive list of decisions relevant to the coronial jurisdiction.


    Queensland decisions

    Atkinson v Morrow [2005] QCA 353; [2006]1 Qd R 397 (05/4253) Brisb McPherson JA Cullinane J Jones J 23/09/2005

    Magistrates - Coroners - the Coroner and the Coroner's Court - Proceedings at inquest or inquiry – inquest into the death of person who died shortly after being left by police in a remote area – whether coroner exceeded his jurisdiction – whether evidence of senior police officer should have been admitted – whether senior police officer required to give evidence at inquest.

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    Attorney-General for the State of Queensland v Barnes & Anor [2014] QCA 152

    Appeal and new trial – practice and procedure – Queensland – Time for appeal – Extension of time – General principles as to grant or refusal – where the first respondent conducted an inquest into the deaths of two women – where the second respondent was committed to stand trial on a charge of unlawful killing – where the decision to commit the second respondent to stand trial was set aside on judicial review – where the applicant/appellant intervened in the judicial review proceeding – where the applicant/appellant seeks an extension of time to appeal against the substantive decision on the ground that the trial judge erred in his analysis of the first respondent’s findings regarding the admissibility of lies – where there was some explanation for the delay – where there was no real prejudice to the respondent – where there were no real prospects of success on appeal – whether an extension of time should be granted.

    Appeal and new trial – practice and procedure – Queensland – powers of the court – costs – where the applicant/appellant intervened in the judicial review proceeding overturning the first respondent’s decision to commit the second respondent to stand trial – where costs were awarded against the applicant/appellant – whether the trial judge erred in applying irrelevant criteria in exercising his discretion as to costs – whether the trial judge erred in awarding costs against the applicant/appellant rather than the State – whether the appeal against costs should be allowed.

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    Beale v O’Connell [2017] QSC 127

    Administrative law – Judicial review – Reviewable decisions and conduct – Review of particular decisions – where the applicant was committed for trial by a magistrate on a charge of manslaughter in relation to the death of the applicant’s wife – where the Director of Public Prosecutions declined to present an indictment on the charge – where the first respondent decided to hold an inquest into the death – where the applicant submitted at a pre-inquest hearing that the first respondent should revoke the decision to hold an inquest – where the first respondent declined to revoke the decision to hold an inquest – where the applicant argued that the first respondent’s decisions were invalid on the basis that the first respondent had failed to take into account relevant considerations and had acted unreasonably – whether the first respondent’s decisions were invalid.

    Administrative law – Judicial review – Reviewable decisions and conduct – Review of particular decisions – where the applicant was committed for trial by a magistrate on a charge of manslaughter in relation to the death of his wife where the Director of Public Prosecutions declined to present an indictment on the charge – where the first respondent decided to hold an inquest into the death – where the first respondent decided to call certain persons as witnesses at the inquest – where the applicant challenged the decisions to call certain witnesses – whether the first respondents’ decisions were invalid.

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    Commissioner of Police v Clements and Ors [2005] QSC 203; [2006]1 Qd R 210 (05/3421) Brisb Wilson J 22/07/2005

    Administrative law - Judicial review - Grounds of review - Error of law - where inquest by Coroners Court – where decision by Deputy State Coroner to allow counsel inspection of certain documents – whether the Deputy State Coroner erred in finding the existence of a legitimate forensic purpose – where the pursuit of the information for use in cross-examination as to credit a legitimate forensic purpose.

    Administrative law - Judicial review - Reviewable decisions and conduct - Decisions to which judicial review legislation applies - Meaning of decision - Generally – where “decision” by Deputy State Coroner in relation to rights to make submissions pursuant to s 36 of the Coroners Act 2003 (QLD) – whether of operative or determinative effect.

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    Cresswell v Attorney-General for the state of Queensland [2018] QSC 142

    Health law – Assisted reproduction regulation – where the applicant applies for declarations that she is entitled to possession of sperm of her late partner, extracted shortly after his death pursuant to an order of this Court, for use in assisted reproductive treatment – where the Transplantation and Anatomy Act 1979 (Qld) applies to the removal of sperm from a deceased person in Queensland – where there is no statutory regime in Queensland that applies to the use of posthumous sperm – where authorities diverge as to the Court’s power to order removal of sperm from a deceased person and whether there is any power to grant final relief – whether there was compliance with the Transplantation and Anatomy Act 1979 (Qld) in removing the sperm.

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    Davis v Ryan [2018] QDC

    Coroners Act, application to hold inquest where state coroner has refused the application, whether inquest would be “in the public interest”.

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    Doomadgee and Anor v Clements and Ors [2005] QSC 357; [2006]2 Qd R 352 (05/9137) Brisb Muir J 22/12/2005

    Administrative law - Queensland - Grounds for review - Improper exercise of power - Powers and discretion of Court - coronial inquest into death of an aboriginal man in police custody on Palm Island – coroner made preliminary ruling as to what evidence she would consider in making her findings under s 45 and s 46 of the Coroners Act 2003 (Qld) (“the Act”) – application made under Judicial Review Act 1991 (Qld) that coroner erred in accepting propensity evidence under s 46 of the Act – applicant contends such evidence not “connected with” a death under s 46(1) of the Act – scope of “connected with” – whether coroner exercised her discretion consistently with object of the Act – whether court should intervene in interlocutory decision of coroner – separate application made under Judicial Review Act 1991 (Qld) that coroner erred in excluding evidence of two complainants when making her findings under s 45 of the Act – applicant contends coroner erred in ruling such evidence was “impermissible” for her consideration and that she should “adopt a more restrictive view” with regards to it – whether coroner applied an erroneous principle of law in coming to her decision – whether coroner bound by legal principle to consider complainants’ evidence in her determination.

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    Gentner v Barnes [2009] QDC 307

    Coroners Act, application to hold inquest where State Coroner has refused the application, whether inquest would be “in the public interest’, nature of test to be applied, consideration of State Coroners Guidelines in relation to inconsistency and/or uncertainty in evidence relating to the cause of fatal accident, consideration of views of family of deceased person in relation to the issue of public confidence in the administration of justice, delay and consideration of earlier decision by local Coroner to hold inquest.
    Gentner v Barnes [2009] QDC 307 (09/0040) Maroochydore Robertson DCJ 30/09/2009

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    Gentner v Callaghan & Ors [2014] QDC 123 (30 May 2014)

    Coroners – the Coroner and the Coroner's Court – application to set aside coroner’s finding – where Coroner made a finding that the cause of death was the deceased losing control of his motorcycle and travelled into the path of an oncoming vehicle but did not directly identify how and why such loss of control occurred – where applicant seeks to have the finding set aside upon the basis of the absence of a particular finding as to a contributing factor, in the nature of suggested debris left on the roadway after adjacent drilling operations – whether Coroner’s finding could not be reasonably supported by the evidence – whether new evidence casts doubt on the finding.

    Coroners – the Coroner and the Coroner's court – application to set aside Coroner’s finding – interpretation of s 50(5) Coroners Act 2003 - where applicant seeks to have the finding set aside upon the basis that new evidence casts doubt on the finding – what constitutes “new evidence” under s 50(5)(a) of the Coroners Act - whether there is any such evidence “which casts doubt on the finding” – what constitutes “the evidence” under 50(5)(d) - whether new evidence casts doubt on the finding – whether evidence excluded or not considered at the inquest forms part of “the evidence” for the purposes of s 50(5)(d) and/or may be considered as ‘new evidence” for the purposes of s 50(5)(a).

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    Goldsborough v Bentley [2014] QSC 141

    Magistrates – Coroners – Inquests and Inquiries – Proceedings at Inquest or Inquiry – Findings, Recommendations and Comments – where the Northern Coroner was conducting an inquest into a death – where the Office of Fair and Safe Work Queensland (OFSWQ) had investigated the death and made a decision not to prosecute – where the coroner directed an employee of OFSWQ to answer a question relating to the decision not to prosecute – whether the coroner can investigate the reasoning of the decision not to prosecute – whether the coroner can comment upon the decision not to prosecute.

    Administrative Law – Judicial Review – Grounds of Review – Jurisdictional Matters – where the Northern Coroner was conducting an inquest into a death – where the Office of Fair and Safe Work Queensland (OFSWQ) had investigated the death and made a decision not to prosecute – where the coroner directed an employee of OFSWQ to answer a question relating to the decision not to prosecute - whether, in directing the question to be answered, the coroner was acting outside the scope of her powers under the Coroners Act 2003 (Qld).

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    Hurley v Clements and Ors [2009] QCA 167 (09/0494) Brisb McMurdo P Keane JA Fraser JA 16/06/2009

    Magistrates - Coroners - The Coroner and the Coroner's Court - Inquests and inquiries generally - where Coroner made findings that first respondent punched the deceased and that those punches caused the injuries that caused the deceased to die – where undisputed medical evidence provided that "severe compressive force" caused the injuries that caused the deceased to die – where undisputed medical evidence provided that punches by first respondent could not have applied severe compressive force necessary – whether finding that punches by first respondent caused fatal injuries to deceased reasonably open on the evidence.

    Magistrates - Coroners - The Coroner and the Coroner's Court - Proceeding at inquest and inquiry - in general - where Coroner made findings as required by s 45 of the Coroners Act 2003 (Qld) – where Coroner to make findings as to what caused a person to die – where Coroner made findings that person's death not caused by a particular agent – whether Coroner permitted to make such findings by the Act.

    Magistrates - Coroners - The Coroner and the Coroner's Court - Proceeding at inquest and inquiry - in general - where State Coroner required to issue guidelines under s 14 of the Coroners Act 2003 (Qld) – where guidelines stipulate that Briginshaw standard of proof applies to proceedings – whether Coroner correctly applied standard of proof.

    Magistrates - Coroners - The Coroner and the Coroner's Court - Powers of superior court - other matters - where appellant applied to District Court to set aside findings of Coroner – where appellant argued that finding could not be reasonably supported by the evidence – where District Court judge set aside findings and appellants appealed to Court of Appeal – where District Court judge incorrectly approached matter by reference to reasonable hypotheses consistent with innocence – where Court of Appeal determines appeal by way of rehearing – where decision of District Court judge correct but process of reasoning flawed – what orders should be made by the Court of Appeal in exercising the powers of the District Court under s 50 of the Coroners Act 2003 (Qld).

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    Kontvainis-Hay v Hutton [2012] QSC 1094 Brisbane Douglas J 12 November 2012

    An application for a declaration that the applicant was entitled to possession and control of the body of the deceased – discussion of whether coroner had power to make decision.

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    Laing v Laing [2014] QSC 194 (22 August 2014)

    Succession - Personal representatives – Rights powers and duties – Disposal of body.

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    Liston v Pierpoint Supreme Court of Queensland No. 7292 of 2009

    An application for a declaration that the applicant, Lenora May Liston, is entitled to possession and control of the body of her deceased daughter for the purpose of burial in the Charleville cemetery.

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    Lockwood v Barnes [2011] QDC 084 (10/1582) Brisb Dorney QC DCJ 3/06/2011


    Inquest – application to District Court for Order – “public interest” – whether views of family (or community) alone sufficient.

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    Milu v WJ Smith and Ors [2003] QSC 430 (18 December 2003)

    The Applicant seeks judicial review of a coroner’s decision that the death of Andrew Daniel Milu was caused by his inexperience as a motorcycle rider. He seeks orders setting aside the coroner’s decision and remitting the matter for further consideration with directions.

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    Nona & Anor v Barnes & Anor [2012] QCA 346 (7 December 2012)

    ADMINISTRATIVE LAW – JUDICIAL REVIEW – REVIEWABLE DECISIONS AND CONDUCT – MEANING OF DECISION – PARTICULAR CASES – where appellants’ brother was one of several people who died when a vessel was lost in Torres Strait – where appellants were represented at inquest conducted by respondent, the State Coroner – where inquest found loss of vessel and deaths “totally avoidable disaster” caused by people failing to carry out duties over many months – where respondent did not refer matter to Director of Public Prosecutions – where s 48(2) of Coroners Act 2003 requires coroner to refer matter to Director of Public Prosecutions if reasonably suspects a person has committed an indictable offence – where appellants, once aware of no referral, enquired about decision not to refer to Director of Public Prosecutions and requested Coroner discharge duty to consider whether to refer – where Coroner responded that no basis on which to make referral and refused to provide reasons for that conclusion – where appellants argued that primary judge erred in holding that Coroner’s “conclusion” prior to manifestation in correspondence or otherwise did not amount to a decision under Judicial Review Act 1991 – where appellants argued Coroner’s “conclusion” was a “determination” or the refusal of a “determination” – where appellants argued Coroner’s conclusion should be regarded as affecting legal rights or obligations because a contrary conclusion would have created a legal obligation in Coroner to give information to Director of Public Prosecutions – where Attorney-General argued primary judge’s decision correct as Coroner’s conclusion did not affect or give rise to any legal rights or obligations – whether Coroner’s conclusion a “decision” to which the Judicial Review Act 1991 applied – whether Coroner required to provide reasons
    ADMINISTRATIVE LAW – JUDICIAL REVIEW – REVIEWABLE DECISIONS AND CONDUCT – EXCLUDED DECISIONS – OTHER DECISIONS – where Attorney-General argued that entitlement to reasons for decision excluded by s 31 of Judicial Review Act 1991 – whether appellants’ entitlement to reasons excluded.

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    Nona and Anor v Barnes [2012] QSC 35 (29 February 2012)

    ADMINISTRATIVE LAW – JUDICIAL REVIEW – REVIEWABLE DECISIONS AND CONDUCT – DECISIONS TO WHICH JUDICIAL REVIEW LEGISLATION APPLIES – MEANING OF DECISION – where the applicant challenges the respondent’s failure to refer its findings to the Director of Public Prosecutions – where the applicant sought reasons why no referral was made – whether the coroner made a decision as defined by the Act requiring him to publish reasons for that decision.

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    R v Raymond [2018] QSC 97

    Criminal law – particular offences – acts injurious to the public in general – nuisances – misconduct relating to corpses – duty for disposition of a human body or human remains – whether the law imposes a duty to properly dispose of the dead - whether such a duty was imposed upon the accused.

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    Walter Mining Pty Ltd v Coroner Hennessey and Ors [2009] QSC 102 (09/0064) Rock'n McMeekin J 7/05/2009

    Administrative law - Queensland - Judicial review - Grounds of review - improper exercise of power - powers and discretion of the Court - Coronial inquest into death of Mr Jason Blee – coroner made preliminary ruling as to what evidence she would consider in making her findings under s 45 and s 46 of the Coroners Act 2003 (Qld) - application made under Judicial Review Act 1991 (Qld) that coroner erred in accepting opinion evidence - whether opinion evidence admissible - whether court should intervene in interlocutory decision of coroner.

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    Wright v. The State Coroner [2016] QSC 305 (16 December 2016)

    Magistrates – Coroners – Inquests and inquiries – Proceedings at inquest or inquiry – Witnesses – where the Coroner held that the applicant is required to give evidence before a s 10 Coroner’s Act 1958 (Qld) inquiry – where the applicant seeks a declaration that a s 10 inquiry under the Coroner’s Act 1958 (Qld) does not abrogate the common law privilege against self-incrimination – where the applicant submits s 34 of the Coroner’s Act 1958 (Qld) does not expressly oust the right to claim privilege against self-incrimination in respect of questions about s 10 inquiries – whether the applicant can be compelled to answer questions for the s 10 inquiry pursuant s 34 of the Coroner’s Act 1958 (Qld).

    Evidence – Adducing evidence – Witnesses – Competence and compellability – Compellability – where the Coroner held that the applicant is required to give evidence before a s 10 Coroner’s Act 1958 (Qld) inquiry – where the applicant submits that pursuant to the legality principle the Coroner’s Act 1958 (Qld) does not expressly abrogate the right to claim privilege against self-incrimination – whether s 34 of the Coroner’s Act 1958 (Qld) does expressly oust the right to claim privilege against self-incrimination in respect of questions about s 10 inquiries

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    Yu v Attorney-General for the State of Queensland; Yu and Ors v Department of Justice and Attorney-General & Anor [2010] QSC 195 (4 June 2010)

    Administrative law - Queensland - Judicial review - Grounds of review - Reasonableness - where children of deceased requested an inquest into their mother’s death – where inquest held and State Coroner found that there was no fault on the part of the hospital in relation to the death – where family requested re-opening of the inquest pursuant to s47(1) of the Coroners Act 1958 (Qld) – where Attorney-General declined the application to re-open the inquest – where children applied for statutory order of review of the decision - whether Attorney-General’s decision so unreasonable that no reasonable decision-maker could properly have arrived at it.

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    Interstate decisions

    Annetts v McCann [1990] HCA 57; (1990) 170 CLR 596 (20 December 1990)

    Coroners (W.A.) - Inquest - Right of parents of deceased to be heard - Extent of right - Coroners Act 1920 (W.A.), s. 24.

    Administrative Law - Natural justice - Application to coronial inquest - Right of parents of deceased to be heard - Extent of right - Coroners Act 1920 (W.A.), s. 24.

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    R v Bain (No 2) [2018] SADC 88

    Reasons for Ruling of Her Honour Judge Chapman

    Criminal law - Evidence - Confessions and admissions - Statements - Record of interview - Discretion to exclude

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    Barci v Heffey [1995] VSC 13; [1995] VICSC 13 (1 February 1995)

    Coroners - representation

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    Bilbao v Farquhar and Ors Court of Appeal: Moffitt P., and Hutley and Glass JJ.A. July 3, 4; Aug. 16, 1978

    Coroners—Inquest into death of person while in custody—Inquest commenced—Charge of murder against police officers—Inquest adjourned—Police discharged at conclusion of committal proceedings—Decision by coroner not to resume inquest—Court has power to quash inquest, though not completed, and to order another inquest—Meaning of “inquest ¼ has been held”—Coroners Act, 1960, ss. 28 (3), 37 (2).

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    Bissett v Deputy State Coroner [2011] NSWSC 1182 (7 October 2011)

    Courts - evidence - non-publication order

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    Burns v The Queen [2012] HCA 35 (14 September 2012)

    Criminal law – Manslaughter by unlawful and dangerous act – Appellant party to joint enterprise to supply methadone to deceased – Deceased died from combined effect of methadone and prescription drug – Whether appellant's supply of prohibited drug to deceased unlawful and dangerous act – Whether sufficient evidence to warrant order for new trial on basis that appellant administered or assisted in administering drug to deceased.

    Criminal law – Manslaughter by criminal negligence – Appellant party to joint enterprise to supply methadone to deceased – Deceased suffered adverse reaction to drugs in appellant's presence – Appellant failed to obtain medical treatment for deceased – Whether appellant under legal duty to take steps to preserve deceased's life.

    Words and phrases – "legal duty", "omission", "supplier of prohibited drug", "unlawful and dangerous act".

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    Cahir v Jamieson and Ors [2010] VSC 285 (25 June 2010)

    CORONER’S – Inquest – Judicial review – Whether findings open – Whether findings should be quashed – Availability of certiorari – Appropriateness of declaratory relief – Occupational Health & Safety Act 1985, s 25 – Occupational Health & Safety Act 2004, s 25 – Coroners Act 1985, ss 19, 21 and 59 – Coroners Act 2008, ss 83 and 87 and Schedule 1.

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    Chaloner & Anor. v Australian Capital Territory [2013] ACTSC 269 (23 December 2013)

    HUMAN RIGHTS – deceased subjected to medical treatment without her free consent: 10(2) Human Rights Act 2004 (ACT) – no allegation of vicarious liability of Australian Capital Territory being the relevant legal entity responsible for Canberra Hospital as a “public authority”: s 40.

    HUMAN RIGHTS – Statutory Interpretation – victim for purposes of ss 40B, 40C Human Rights Act, only person whose right is infringed – granddaughters of victim are not victims themselves STATUTORY INTERPRETATION – deceased death preceded in time by negligent medical procedure – when Court can make order directing coroner to conduct hearing into death: s 91 Coroners Act 1997 (ACT) – whether in the interests of justice – where no evidence negligence was cause of death JURISDICTION PRACTICE AND PROCEDURE – whether ACT executive capable of being made a party to proceedings – where executive conferred power by legislation and Court is asked to make rules in relation to the exercise of power JURISDICTION PRACTICE AND PROCEDURE – whether Court can order appointment of board of inquiry: s 5 Inquiries Act 1991 (ACT) – whether Court can order statutory discretion to be exercised in a particular way – mandatory injunction.

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    Conway v Jerram, Magistrate and NSW State Coroner [2011] NSWCA 319 (28 September 2011)

    CORONERS - inquest into death - jurisdiction of coroners - application to Supreme Court to require an inquest to be held - whether "manner and cause" of death have not been sufficiently disclosed - relevance of events preceding death to "manner and cause" of death - scope of "the interests of justice"

    APPEAL - leave to appeal - interlocutory orders and judgments - refusal to order inquest is interlocutory - did not involve an amount of $100,000 or more

    APPEAL - interference with discretion of court below - discretionary decision about what interests of justice require - House v The King standard of appellate review.

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    Danne v Hendtlass (sitting as CORONER)- BC201207512

    ADMINISTRATIVE LAW -- Hearing rule of natural justice -- Legal professional privilege -- Whether a coroner is authorised to provide material to an interested party on condition that a copy of any report prepared for that party on that material be provided to the coroner -- Such a condition undermines the hearing rule of natural justice and legal professional privilege and is invalid.

    CORONERS COURT -- Power of a coroner to impose conditions on the provision of material to an interested party -- Whether a tissue sample taken from a body remains part of the body -- Whether a coroner has control over the tissue sample -- Whether legal professional privilege under the common law or under the Evidence Act 2008 applies -- Coroners Act 2008 ss 22, 28, 47, 49, 56, 58, 62, 66, 67, 114, 115 and the definition of "body" in s 3(1) -- Human Tissue Act 1982 ss 27, 29, 30, 33; Evidence Act 2008 ss 118, 119, 131A.

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    Darcy v Duckett [2016] NSWSC 1756 (9 December 2016)

    Intestacy – burial rights – dispute between de facto spouse and sibling – significance of Aboriginal cultural, spiritual and religious beliefs – ascertaining relevant circumstances

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    Domaszewicz v State Coroner [2004] VSC 528 (17 December 2004)

    Coroners - findings made without inquest - subsequent order that inquest he held - false basis for assumption of jurisdiction to hold inquest - whether alternative basis for assumption of jurisdiction existed - whether all conditions antecedent to exercise of jurisdiction on available basis satisfied - whether coroner required to make finding in respect of matter dealt with by now-repealed s. 19(1)(e), Coroners Act 1985 - whether risk, in substance, of double jeopardy.

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    Evans v Northern Territory Coroner [2011] NTSC 100 (6 December 2011)

    CORONER – objection to autopsy – Coroner’s duties, responsibilities and powers – unexplained death of an infant – Aboriginal culture and law – interests of the family to be weighed against the public interest.

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    Gilliott v Woodlands [2006] VSCA 46 (8 March 2006)

    Coroners – Statutory duty to issue certificate permitting release of body for disposal – Coroners Act s.23(1) – Implied power to decide mode of disposal and to decide by whom and where body is to be disposed of – No merits review of Coroner’s decision – Judicial review only.

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    Harmsworth v The State Coroner – [1989] VR 989

    Coroners – Inquest – Powers of investigation, comment and recommendation – Extent of powers – Matters “connected with” death.

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    Hecht v Coroners Court of Victoria [2016] VSC 635 (17 November 2016)

    Administrative law – Appeal pursuant to s 84 of the Coroners Act 2008 (Vic) – Application pursuant to s 77 to set aside findings – Interests of justice s 87A – Question of law s 87 – New facts and circumstances – Test for new facts and circumstances under s 77 – Discretion of coroner to set aside findings - Senior next of kin not notified of potential for adverse findings – Denial of procedural fairness.

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    Irfani -v- The State Coroner [2011] WASC 270 (3 October 2011)

    Coroner's practice - Deceased in immigration detention - Passage of many years - Whether an inquest is appropriate.

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    Josephine Conway v Mary Jerram, Magistrate and NSW State Coroner and Anor [2010] NSWSC 371 (3 May 2010)

    Coroner - Inquest into death - whether inquest should be ordered - manner and cause of death - limits of jurisdiction – remoteness.

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    Helicopter Resources Pty Ltd v Commonwealth of Australia (No 2) [2018] FCA 991

    ADMINISTRATIVE LAW – inquest by the Chief Coroner of the Australian Capital Territory – where subject matter of inquest has a measure of overlap with pending criminal charges against the corporate applicant and the Commonwealth – application to restrain the Coroner from requiring the applicant’s employee to give evidence – whether requiring the employee to give evidence would pose a real risk of interference with the administration of justice and constitute a contempt of court – whether the Coroner has statutory power under the Coroners Act 1997 (ACT) to require the applicant’s employee to give evidence if it would otherwise constitute a contempt of court – principle of legality – consideration of principles in Lee v New South Wales Crime Commission  [2013] HCA 39;  251 CLR 196 – Held: application dismissed with costs.

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    Peter Lucas-Smith and Ors v Coroner’s Court of the Australian Capital Territory and Ors [2009] ACTSC 40 (8 April 2009)

    Courts and Tribunals – “The Canberra firestorm” – bush fire coronial inquest – the issue for consideration by the inquest – ‘cause and origin of a fire that has destroyed or damaged property’ – adverse comments made by coroner against persons responsible for controlling and suppressing rural fires – application to have adverse comments made quashed – coroners obligation to afford procedural fairness – natural justice – attribution of blame – jurisdiction of the Supreme Court to quash adverse comments or order fresh inquiry – exclusion of consideration of the actions of the NSW authorities.

    Coroners Act 1997 (ACT) – ability of the Coroner to make adverse comments – s18 jurisdiction of the Coroner – whether the attribution of blame exceeds the authority of the Coroner – compliance with the legislation – form of notice under s 55 'notice of intended adverse comments' – limitation of s 93 – ability of parties to respond to s 55 notice – the Coroner’s discretion to make comment on matters ‘connected with’ the fire – whether the comments made by the Coroner were open on the evidence.

    Human Rights Act 2004 (ACT) – s 12(b) – right to vindicate reputation

    Jurisdiction– jurisdiction of Coroner – whether the Coroner incorrectly define her jurisdiction – the Australian constitution – s 122– power to make laws having an extraterritorial effect – scope of inquiry – issue at inquest – inquiry need not be confined by ACT border – sufficient connection to the ACT – limited by relevance.

    Evidence – appointment of consultant expert by the Coroner – witness testimony – ostensible bias – preference of the evidence of one particular witness not evidence of bias – whether a fair minded lay observer would reasonably apprehend bias.

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    Mapapalangi and Anor v State Coroner of Victoria [2008] VSC 535 (28 November 2008)

    Coroner – Autopsy – Infant – Application for order that no autopsy be performed – Tongan culture and beliefs – Coroners Act 1985, s 29(4).

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    Musumeci v Attorney General of NSW and Anor [2002] NSWSC 425 (17 May 2002)

    Coroner: inquest into death by shooting - plaintiff a suspect - granted leave to appear - whether entitled to all relevant material at early stage of inquest - when question of referral to DPP under S 19 arises.

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    Musumeci v Attorney General of NSW and Anor [2003] NSWCA 77 (9 May 2003)

    Coronial inquest - Coroners Act 1980, s 19 - Requirements of procedural fairness - Nature of a coronial inquest - Stage at which procedural fairness requires the disclosure of all relevant material to a witness whose interests might be adversely affected by the exercise of the Coroner's powers under s 19 - Circumstances in which the withholding of relevant material from such a witness is necessary to protect the integrity of the investigation - Withholding relevant material for tactical reasons. Musumeci v Attorney General of NSW Anor [2003] NSWCA 77 (9 May 2003)

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    Onuma v The Coroner's Court Of South Australia [2011] SASC 218 (9 December 2011)

    Appeal against findings and recommendations of the Coroner’s Court - Inquest into the deaths of two women who died within months of each other after undergoing surgery performed by the appellant - nature of the appeal - powers and duties of the Coroner under the Coroners Act 2003 (SA) - grounds for interfering with Coroner's findings - whether finding of cause of death of one woman accurate – whether certain findings and recommendations were ultra vires - whether appeal lies to the Supreme Court from a recommendation made by the Coroner’s Court - whether the appellant was afforded procedural fairness during the inquest.

    Held: cause of death of one woman inaccurate and incomplete - no evidence to justify comments concerning the competence and qualifications of the appellant to conduct the surgery performed on the two women - no right of appeal from a recommendation of the Coroner - appellant was afforded procedural fairness during the inquest - appeal allowed on grounds 1, 2, 3, 6, 7 and 11.3 - grounds 5, 8, 9, 10, 11.1 and 11.2 dismissed - not necessary to decide whether findings made beyond power of court (ground 4).

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    Perre v Chivell No. SCGRG-99-1218 [2000] SASC 279 (24 August 2000)

    Application by the plaintiff to set aside coroner's findings - coroner found that the plaintiff sent the bomb which killed Sergeant Bowen, the subject of the coronial inquiry - whether this constituted a "finding, or suggestion of criminal or civil liability" - whether s 26(3) of the Coroners Act 1975 thereby breached - whether an irregularity occurred by reason of the coroner's reliance on the decision in Weissensteiner v R. HELD: No breach of s 26(3) - it was unnecessary for the coroner to rely on the decision in Weissensteiner v R - no miscarriage or irregularity as a result of reliance - orders sought by plaintiff refused.

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    Priest v West & Anor [2012] VSCA 327 (20 December 2012)

    ADMINISTRATIVE LAW – Coroner – inquest into the death of a child – Reportable death – Obligation to find, if possible, the cause of death and circumstances in which the death occurred – Coroner excluded statements about the circumstances of the deaths of five other children – Propensity evidence – Whether statements were relevant considerations that the Coroner was obliged to take into account – Pfennig v The Queen [1995] HCA 7; (1995) 182 CLR 461 – Section 67(1)(b) and s 67(1)(c) of the Coroners Act 2008 (Vic).

    CORONER – Whether witness should be compelled to give evidence under s 57(4) of the Coroners Act 2008 (Vic) – Reliability of the evidence relevant to whether the ‘interests of justice’ required that witness give evidence – Inquisitorial character of coronial inquest – Weinstein v Medical Practitioners Board of Victoria [2008] VSCA 193; (2008) 21 VR 29 – Distinction between ‘salient facts’ and mere ‘pieces of evidence’ – Macedon Ranges Shire Council v Romsey Hotel Pty Ltd [2008] VSCA 45; (2008) 19 VR 422.

    STATUTORY INTERPRETATION – Section 57(3) of the Coroners Court Act 2008 (Vic) – Whether Coroner obliged to inform witness that he would be given a certificate of immunity if he willingly gave evidence – Appeal allowed.

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    R v Doogan [2005] ACTSC 74 (8 August 2005)

    Coronial inquiry - application for prohibition on ground of apprehended bias - relevant principles - significance of jurisdictional limits and hybrid nature of inquiry - ostensibly independent investigator not appointed by Coroner but engaged by department - danger of blurring boundaries between judicial and executive arms of government.

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    Raymond-Hewitt v Northern Territory Coroner [2011] NTSC 94 (22 November 2011)

    Coroner – objection to autopsy – Coroner’s duties, responsibilities, and powers – motor vehicle collision – reportable death – whether autopsy to be performed – considerations in favour of autopsy – cultural and spiritual considerations – statistics of motor vehicle accidents

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    R v Tennent; Ex parte Jager [2000] TASSC 64 (9 June 2000)

    Magistrates - Coroners - The Coroner and the Coroner's Court - Proceedings at inquest or inquiry - In general - Whether belief of Coroner that a crime has been committed the proper subject of address by counsel - Whether such address impliedly prohibited by statute.

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    Re the State Coroner; Ex parte the Minister for Health WASCA 165 (18 September 2009)

    Coroners - Inquest - Application to review - The character of an inquest under the Coroners Act 1996 (WA) - The nature of a 'finding' within s 25(1) - The nature and ambit of the 'findings' which a Coroner must make, if possible, under s 25(1) - The character of an application to the Supreme Court under s 52(1) - Whether a 'finding' within s 25(1) is different from a 'finding' within s 52 - What an applicant under s 52(1) must establish in order to satisfy the Supreme Court that the Coroner's 'findings' are against the evidence or the weight of the evidence.

    Coroners - Inquest - Application to review - Whether impugned statements in a Coroner's Report were 'findings' within s 25(1) of the Coroners Act 1996 (WA) - Whether the impugned statements were critical of a psychiatrist who had treated the deceased - Whether the impugned statements were against the evidence, or the weight of the evidence, adduced at the inquest - Whether it was open to the Coroner to conclude that the criteria in s 26 of the Mental Health Act 1996 (WA) were satisfied in relation to the deceased when he last consulted with a psychiatrist - Whether the Coroner failed to accord the appellant procedural fairness before making the impugned statements.

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    S v The Director of Public Prosecutions and Ors [2007] ACTSC 100 (21 December 2007)

    Separation of powers – whether appropriate for a Registrar of the Magistrates Court to act as a Coroner – whether appropriate for ACT Public Servant to adjudicate mater if ACT is an interested party.

    Coroners report – Quashing of comments – whether adverse comments were supported by evidence – whether applicant given procedural fairness.

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    Taing and Nuon v Territory Coroner and Attorney-General for the Northern Territory [2011] NTSC 58 (9 August 2011)

    Plaintiff seeks an order that an inquest be held - both parties accept the deaths of the deceased persons are reportable deaths over which the coroner has jurisdiction to investigate – question requires consideration of whether an inquest would raise a real possibility of determining the cause of death or enable further significant finding be made– if holding an inquest would be futile no order should be made.

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    Thales Australia Limited v The Coroners Court of Victoria and Anor [2011] VSC 133 (11 April 2011)

    Coroners – Inquest – Appeal on a question of law – Judicial review – Whether finding open – Fragmentation of inquest – Circumstances in which death occurred – Power of Coroner to comment on any matter connected with the death – Coroners Act 2008

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    Threlfall v Threlfall and Anor [2009] VSC 283 (8 July 2009)

    Coroner – release of body for burial – coroner’s determination as to person to whom body should be released – body released to brother of the deceased in preference to widow - entitlement of next of kin – whether coroner considered this entitlement - whether error of law –Coroners Act 1985 s. 23(1).

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    Traynor v Spooner [2012] VSC 651 (3 December 2012) Coroners Court

    Appeal on a question of law against Coroner’s direction to perform autopsy – Coroner believed autopsy necessary for investigation of death – Death appears accidental – No evidence of foul play – Mechanism of death known – Not open to find autopsy necessary – Coroner required to consider whether autopsy appropriate as well as necessary – Coroner failed to consider whether autopsy appropriate – Errors of law made out – Appeal allowed – Autopsy should not be performed – Consideration of approach to be taken by Coroner in appeals under Pt 7 of Coroners Act 2008 – Coroners Act 2008 ss 25, 26, 67, 79(1), 88.

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    Ugle v Bowra & O'Dea & Anor [2007] WASC 82 (16 March 2007)

    Administration - Possession of a body for burial - Determination by Coroner

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    Veitch -V- The State Coroner [2008] WASC 187 (3 September 2008)

    Coroners - Coroner declined to hold an inquest - application that an inquest be held - whether necessary or desirable in the interests of justice - whether any possibility of a different verdict - turns on own facts.

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    Victoria Police SOG Operators 16, 34, 41 and 64 v Coroners Court of Victoria [2013] VSC 246 (16 May 2013)>

    ADMINISTRATIVE LAW — Natural justice — Application to prevent a coroner from continuing with an inquest on the ground of apprehended bias — Whether coroner prejudged issues and the plaintiffs’ credit by forming a belief under s 49(1) of the Coroners Act 2008 that the plaintiffs may have committed an indictable offence and by questioning their motives for seeking to give evidence under the protection of a certificate pursuant to s 57(5) of that Act — Application dismissed.

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    International decisions


    Black Action Defence Committee v. Huxter, Coroner 11 O.R. (3d) 641; 1992 Ont. Rep. LEXIS 71 December 21, 1992

    Coroners - Inquest - Standing - Mentally ill member of black community fatally shot by police officer - Trial of police officer and investigation by O.P.P. revealing no evidence that race was direct factor in shooting - Coroner correctly denying standing to organization which sought to raise concerns of black community that race played direct role in shooting  Organization not having substantial and direct interest in inquiry – Coroner erring in denying standing to organization with expertise on need for cross-cultural training in dealing with mentally ill -- Issue to be raised at inquest by at least one witness - Issue not peripheral - Organization having direct and substantial interest in issue - Coroners Act, R.S.O. 1990, c. C.37, s. 41(1)

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    Carroll v Coroner's Court at Auckland [2013] NZHC 906 (29 April 2013)

    Application to have findings quashed on the grounds they were unreasonable because there was no evidence upon which it could properly be based. Secondly, it was made in breach of s 15(2)(b) of the Coroners Act 1988 (the Act), which obliged the Coroner to give the applicants prior notice of his intention to comment adversely upon their conduct and an opportunity to be heard in relation to that comment. Finally, they say that the finding was otherwise made in breach of the principles of natural justice because the applicants had no notice that their conduct was likely to be the subject of scrutiny at the inquest.

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    Coroner for the Birmingham Inquests (1974) v Hambleton & Ors [2018] EWCA Civ 2081 26 September 2018

    Reopened inquest, Birmingham Inquests (1974) - whether the decision not to explore the "Perpetrator Issue", that is to call evidence directed to identifying those who planned, planted, procured and authorised the bombs used on 21 November 1974, was lawful.

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    Fardell v The Attorney-General on behalf of the Coroner's Court at North Shore and Auckland HC AK CIV 2006-404-3638 [2006] NZHC 133 (1 November 2006)

    Jurisdiction – jurisdiction of Coroner's Court to forbid the publication of evidence given before it –in  what circumstances ought the open justice principle yield to (the predominantly) private interests of the deceased and his or her family.

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    Gravatt v The Coroner’s Court at Auckland [2013] NZHC390 4 March 2013

    Order prohibiting publications of names in inquest findings.

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    R v Coroner for the Southern District of Greater London; ex parte Driscoll Queen's Bench Division (Crown Office List) 159 JP 45, CO/2609/93

    An application for judicial review of the decision of Her Majesty's Coroner for Greater London (Southern District), who on 6 September 1993 gave notice of his conclusion that in relation to an inquest concerning the death of Peter Swan, Valerie and Pamela Driscoll, who are sisters of the deceased, are not properly interested persons within the terms of the Coroner's rr 1984, r 20. That is a rule which enables a coroner to decide who is entitled to examine any witnesses at an inquest.

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    People First of Ontario v. Ontario (Niagara Regional Coroner) 1991 CarswellOnt 705

    Judges and Courts - Coroners - Jurisdiction of Coroner - Nature of inquest - Procedural requirements - Right of coroner to restrict participation of intervenors

    Notwithstanding the emerging public interest in the jury recommendations in the modern Ontario inquest, an inquest is not a Royal Commission. Nor is it a trial, public platform, campaign, lobby or crusade.

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    R v HM Coroner for Derby and South Derbyshire ex parte Hart Queen's Bench Division (Crown Office List) 164 JP 429 7 April 2000

    Coroners law - purpose of inquest - disallowance of questions - verdict of unlawful killing.

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    R v HM Coroner for Inner South London, ex parte Epsom Health Care NHS Trust Queen's Bench Division 158 JP 973 14 July 1994

    Coroners law - purpose of inquest - disallowance of questions - verdict of unlawful killing.

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    Regina v Her Majesty's Coroner At Hammersmith, Ex Parte Peach (Nos. 1 And 2) [Court Of Appeal] [1980] QB 211

    Coroner - Inquest - Jury - Death from blow on head at political demonstration - Suggested unauthorised use of lethal weapon by police - Whether "circumstances... recurrence of which is prejudicial to... health or safety" – Whether coroner bound to summon jury - Coroners (Amendment) Act 1926 (16 & 17 Geo. 5, c. 59), s. 13 (2) (e) - Criminal Law Act 1977 (c. 45), s. 56 (1) (2) Coroner - Inquest - Police statements - Statements taken from witnesses by police - Available to coroner f or his use - Whether disclosable to interested party - Coroners Rules 1953 (S.I. 1953 No. 205), r. 16 (1) n1

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    Regina v Poplar Coroner, Ex parte Thomas [Court of Appeal] [1993] QB 610

    Coroner - Inquest - Duty to hold - Deceased having severe asthma attack - Deceased suffering cardiac arrest while waiting for ambulance - Post mortem showing death by natural causes - Possibility of delay in arrival of ambulance contributing to death - Coroner refusing to hold inquest - Whether reason to suspect that death "unnatural" – Coroners Act 1988 (c. 13), s. 8(1)

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    Stanford v. Ontario (Eastern Regional Coroner) 1989 CarswellOnt 441

    Judges and Courts - Coroners - Coroner's inquest - Procedural requirements – View - Standing - Inquest into suicide of inmate in unique "super-protective custody unit" in penitentiary - Remaining inmates of unit unsuccessfully seeking standing at inquest - Application for judicial review of coroner's decision - Inmates having a "direct and substantial" interest in potential recommendations of inquest - Coroners Act, R.S.O. 1980, c. 93, s. 41.

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    WK Abbott v Coroners Court of New Plymouth and Ors 20 April 2005

    Review of coroner’s decisions to limit the scope of the inquiry and not to hear oral evidence from any of the witnesses who gave evidence in the High Court.

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    Worcestershire County Council, Worcestershire Safeguarding Children Board v HM Coroner for the County of Worcestershire [2013] EWHC 1711 (QB)

    Public interest in the pursuit of a full and appropriately detailed inquest into the death of a child in care, firmly outweighed the child protection agency's claim for non-disclosure of child safety review type documents

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    Related material

    'Reliance on internal autopsies in coronial investigations: A review of the issues'

    This article is ostensibly about rates of internal autopsies in coronial investigations. However, examination of that issue requires consideration of more broad, quite seminal questions about who should decide the scope of those investigations and their purpose.

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    'Privilege limited in commission of inquiry'

    In AWB the Federal Court clearly decided that litigation privilege does not apply to documents brought into existence for use in relation to a commission of inquiry.

    View the decision>>


    Saving lives by joining up justice:

    Why Australia needs coronial reform and how to achieve it Federation of Community Legal Centres (Victoria)6 March 2013.

    View the decision>>

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